Fillable 5216 OCRC Fair Housing Complaint Form (Clark County Board of Commission)

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5216 OCRC Fair Housing Complaint Form (Clark County Board of Commission)

On average this form takes 13 minutes to complete

The 5216 OCRC Fair Housing Complaint Form (Clark County Board of Commission) form is 2 pages long and contains:

  • 0 signatures
  • 40 check-boxes
  • 32 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Clark County Board of Commission

BROWSE CLARK COUNTY BOARD OF COMMISSION (OH) FORMS

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OCRC Use Only
OCRC
Number:
HUD Number:
Name of person or organization alleging harm:
Home Phone Number:
( )
Alternate Phone Number:
( )
Street Address
City
State
Zip
Email address:
Against whom is this charge being filed?
Phone Number
( )
Street Address
City
State
Zip
Check the applicable box or boxes which describe(s) whom the charge is being filed against:
□
Owner
□
Manager
□
Salesperson
□
Bank or other Lender
□
Broker
□
Other
If you named an individual above who appeared to be acting for a company in this case, write the name and address
of the company below.
Name:
Address:
Name and identify others (if any) you believe violated the law in this case:
3a. What is the address of the house or property? (street, city, county, state and zip code):
3b
.
Does the owner live at this address?
□
Yes
□
No
□
Unknown
4. What kind of house or property was involved?
□
Single-Family house
□
A house or building for 2, 3, or 4 families
□
A building for 5 families or more
□
Other, including vacant land held for residential use (explain):
5a. Is this house or property being sold?
□
Yes
□
No
□
Unknown
5b. Is the house or property being rented?
□
Yes
□
No
□
Unknown
Ohio Civil Rights Commission - Housing Discrimination Charge
6. Do you believe you were discriminated against because of your: (Check all that apply.)
□
Race
□
Color
□
Sex
□
Disability
□
National Origin
□
Ancestry
□
Religion
□
Military Status
□
Familial Status
□
Marital Status (mortgage credit only)
□
Retaliation
7. When did the act(s) of discrimination occur? (Include the most recent date if several dates are involved.)
8. What did the person you are complaining against do? (Check all that apply.)
□
Refuse to rent, sell, or deal with you
□
Falsely deny housing was available
□
Discriminate in the terms and conditions in the sale, rental, occupancy, or in services or facilities
□
Deny a reasonable accommodation
□
Deny a reasonable modification
□
Advertise in a discriminatory way
□
Threaten, intimidate, interfere, harass, or coerce you to keep you from the full benefit of the State or
Federal Fair Housing Law
□
Discriminate in financing
□
Engage in blockbusting
□
Engage in steering
□
Other
9. Please write a concise summary of what happened that you believe is an act of discrimination:
I declare under penalty of perjury that the foregoing is true and correct.
Signature: Date:
Sworn and subscribed before me on this day of of 20
Ohio Civil Rights Commission Representative or Notary
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5216 OCRC Fair Housing Complaint Form (Clark County Board of Commission)

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Completed 13 February 2021

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